Presentation
A 33-year-old woman came to the emergency department (ED) reporting bilateral abdominal pain, back pain, and shortness of breath. She reported that she was nine to 10 weeks pregnant. The patient also had a history of pelvic inflammatory disease (PID) and sickle cell anemia.
The patient’s vital signs were normal, but she had tenderness along her abdomen. Blood work indicated that she had a white blood cell count of 8,000 and mild anemia. The emergency medicine physician ordered an ultrasound to determine if the pregnancy was normal.
Physician action
The radiology technician completed the ultrasound and contacted the on-call radiologist at his home at 3 a.m. The technician told the radiologist that the images were of poor quality even though the ultrasound had been done twice. The radiologist had the technician send him a copy of the images via teleradiology. After reviewing the images, he determined that the pregnancy was intrauterine but “abnormal.” He reported this finding by phone to the ED physician. However, the ED physician claimed that the radiologist reported that the ultrasound showed a normal intrauterine pregnancy. “Normal intrauterine pregnancy” was written in the ED records.
The ED physician discharged the patient at 6:40 a.m. after giving her meperidine, promethazine and antibiotics. The final diagnosis was abdominal pain due to intrauterine pregnancy, gastroenteritis, or possible pelvic inflammatory disease. She was told to rest at home and follow up with her obstetrician. The ED physician later stated that the patient was discharged because she refused hospitalization, but this was not indicated in the medical records.
A second radiologist reviewed the ultrasound images when he arrived at 8 a.m. He noted that the ultrasound showed an intrauterine cornual pregnancy, a pregnancy in which implantation occurs in the uterus at its junction with the fallopian tube. He recommended that the patient be brought back in for further studies to evaluate the position of the pregnancy. According to his testimony, he asked the radiology technician to call the patient and have her return. The patient was never called. The technician stated that the radiologist never requested that she call the patient.
The patient continued to suffer from abdominal pain at her home before calling EMS at 9:44 a.m. When she arrived at the hospital, she complained of acute pain and difficulty breathing. Ten minutes later she coded and CPR was started.
She was sent to the OR for an emergency laparotomy due to suspected ruptured ectopic pregnancy. CPR was continued throughout the surgery. The surgeon located and removed the cornual pregnancy from the left side of the uterus and noted between 1.5 and 2 liters of blood in the abdominal cavity. Despite CPR and several defibrillations, the patient was pronounced dead at 12:17 p.m. The pathologist found the cause of death to be ruptured ectopic cornual pregnancy complicated by acute shock and exsanguination.
Allegations
A lawsuit was filed against the radiologists and the ED physician. The allegations included:
- failure to properly interpret the ultrasound resulting in a premature discharge from the ED (first radiologist);
- failure to provide the diagnosis to the ED in a timely manner resulting in failure to call patient back to the hospital (second radiologist); and
- failure to perform a pelvic exam, failure to call for an OB consult, and prematurely discharging the patient (ED physician).
Legal implications
Cornual pregnancies are extremely rare and some physicians may never encounter them in their careers. They also have a high mortality rate and, according to radiology experts reviewing this case, are very difficult to diagnose.
While acknowledging that the poor quality of the ultrasound films, the plaintiff’s radiology expert stated the final diagnosis of intrauterine pregnancy was incorrect. The patient did not have an obvious extrauterine ectopic pregnancy, but a pregnancy in an unusual position that was neither extrauterine nor intrauterine. In any case, according to the plaintiff’s expert, the failure to diagnose the cornual pregnancy led to the patient’s inappropriate discharge from the hospital and her death.
TMLT radiology consultants had mixed opinions about the first radiologist’s interpretation, but all agreed that the images were consistent with a cornual pregnancy. One reviewer commented that the radiologist should have asked for a repeat exam or should have come to the hospital to review the ultrasound. Another consultant stated that the radiologist did not rule out ectopic pregnancy just by advising the ED physician that this was an abnormal pregnancy.
The second radiologist’s interpretation of “an intrauterine pregnancy of questionable location” was considered appropriate, but consultants were concerned that he dictated the need to call the patient back rather than contacting the ED physician. In his deposition, the radiologist said that if he had been certain the patient had an ectopic pregnancy, he would have contacted the patient immediately. Since this diagnosis was a “gray area” and since he was informed that the patient had been discharged from the ED, he asked the technician to contact the patient.
Regarding the actions of the ED physician, plaintiff’s experts stated there was not enough information about the patient’s condition to discharge her. Even after receiving word that the pregnancy was not ectopic, he should have performed a pelvic exam and obtained an ob-gyn consult. A pelvic exam would have yielded additional information to make the diagnosis. An ob-gyn consult should have been ordered because he had a pregnant patient in severe pain without an ectopic pregnancy. Defense experts argued that a pelvic exam was not necessary since an ultrasound had been ordered. An obstetric consult was also not necessary because the patient was already under the care of an obstetrician and it was determined, based on the ultrasound, that her condition was not life threatening.
Of great concern in this case was the communication between physicians and the apparent lack of documentation about what was discussed. The first radiologist should have documented his interpretation by faxing a report to the hospital immediately. Though the ED physician did document that the radiologist reported a “normal intrauterine pregnancy,” he did not document that he wanted to hospitalize the patient but she refused. For the second radiologist, a call to the ED physician advising him of the need for follow-up studies would have been more appropriate than dictating the need for call back in the report.
Disposition
This was a complex case involving multiple physicians. Finger pointing became a concern, as each party to the suit gave differing versions of the events. These facts, along with the lack of documentation and the communication issues, led to the decision to settle the case on behalf of all three physicians. The ED physician contributed 50% and each radiologist contributed 25% to the settlement.
Risk management considerations
In hindsight, actions that might have made a difference in the outcome of this claim have been mentioned above. None of these actions are extraordinary in nature, but reflect a commitment to the delivery of quality patient care and the documentation of that care. Are oral reports acceptable in teleradiology? Was the impression clearly understood when the physicians spoke? It seems unlikely that the ED physician would ignore the word “abnormal.” That is not what he heard. A report emailed or faxed would alert him to “intrauterine but abnormal.” Are images of poor quality satisfactory for interpretation away from the facility? What protocols are in place to determine when the on-call radiologist comes in?
Clearly, communication and timely action may influence outcomes when studies are abnormal and follow up is required. The practice of radiology lends itself to well-defined systems that guide when the ordering physician is told of abnormal findings and any recommendations for further studies. Document this contact. Practicing prudent risk management and implementing well-designed systems to observe the standards of care will promote quality health care and reduce the exposure a radiologist encounters on a daily basis.
